Overtreatment of Sigmoid Diverticulitis: Plea for a Less Aggressive Approach

Abstract

A less invasive approach to the treatment of left-sided colonic diverticulitis has emerged in the last decade. The standard of care for perforated or complicated diverticulitis evolved from a Hartmann’s procedure, to resection and primary anastomosis, to treatment with antibiotics and percutaneous drainage in a carefully selected (Hinchey grade 2) patient subset. Recently, laparoscopic lavage emerged as a promising less invasive treatment for selected cases of Hinchey 3 patients. Likewise, for nonperforated or uncomplicated diverticulitis the approach is becoming less aggressive with a change from intravenous antimicrobial therapy, starvation and admission, to oral antibiotics and finally to observation and outpatient treatment. This less invasive or aggressive approach is due to expanding evidence on optimal treatment and is congruent with an increasing understanding that diverticulitis comprises different disease entities with heterogeneity between patients. The disease should be targeted by specific approaches, after a meticulous assessment of the diverticulitis stage, and tailored to an individual basis. Avoidance of overtreatment has obvious benefits: less in-hospital treatment, cost reduction, diminished development of antimicrobial resistance, reduction in complication rate and side effects and presumably a better quality of life for the patient. In conclusion, one might say we have overtreated the majority of diverticulitis patients for decades. More research is needed to explain the pathogenesis and multifactorial etiology and in the near future hopefully several unanswered questions regarding the optimal management of patients with different stages of diverticulitis will be answered by various ongoing trials.

Surgery for Diverticulitis in the 21st Century

“…Reviewing the published literature on surgical management of diverticulitis since the turn of the millennium, we found substantial changes in contemporary evidence that have reduced the use of urgent surgery for acute diverticulitis, 1,2 restricted the indications for prophylactic surgery in recurrent diverticulitis, 10,31,98 and led a movement to-ward generally less invasive and morbid approaches to this disease. 99 Because of the rapid pace of recent changes in practice patterns, we focused this review on studies with data predominantly since 2000. At that time, the practice parameters of the American Society of Colon and Rectal Surgeons continued to recommend elective surgery after 2 uncomplicated episodes of diverticulitis, until the 2006 practice guideline that acknowledged the need to individualize timing of surgery.…”

Changes in the Surgical Approach to Colonic Emergencies during a 15-Year Period

“…Although considerable progress has been made with regard to surgical techniques and in pre- and postoperative patient care, morbidity and mortality rates for emergency colon surgery continue to range between 11-35% and 9-22%, respectively [14,15,16,17,18,19,20,21,22,23,24]. …”

Validation of a grading system for complicated diverticulitis in the prediction of need for operative or percutaneous intervention

“…Factors to account for such change include increasing incidence of the disease in the younger population, 22 the availability of a wider range of antibiotics, better management of acutely ill patients 16 and increasing use of the minimally invasive approach. 7 All these factors have led to progressive change in policy towards less aggressive treatment. This study adds to the existing understanding of the natural history of this condition as decision making was based on patients' clinical response to treatment with no strict protocols that might lead to 'avoidable' surgical intervention.…”

“…[3][4][5][6] The current surgical management of complicated acute diverticulitis has seen a major paradigm shift from routine operative intervention to a more conservative approach. [7][8][9] This change in practice reflects our increasing understanding of the morbidity and mortality associated with emergency surgery for complicated diverticular disease as well as subsequent interventions attempting to deal with the consequences of the emergency surgery such as stoma complications, incisional hernias and stoma reversal. Historically, surgical intervention was indicated for sepsis source control, which often required laparotomy and resection of the perforated segment of colon and end colostomy formation (Hartmann's procedure).…”